Sunday, January 01, 2017

Rethinking antipsychotic medication

In a comment on my previous post about his article, Robin Murray has highlighted what he calls critical psychiatry's "scepticism about the unthinking advocacy of prophylactic antipsychotics". I think he has in mind a BJPsych article, which discuses the lack of evidence for long-term effectiveness of antipsychotic medication and expresses concern about antipsychotics causing a decrease in cortical volume and dopamine receptor supersensitivity, besides having side effects on physical health. I suspect this article was written in response to Jo Moncrieff's questioning of the need to rethink antipsychotic maintenance treatment (see her article).

Critical psychiatry has always emphasised discontinuation effects from psychotropic medication. Personally I have always pointed to the importance of psychological aspects in discontinuation. Many of the posts on this blog have been about antidepressant discontinuation (eg. see previous post) but the same principles apply to antipsychotic discontinuation. Removing a drug which is thought to have been beneficial is likely to produce a nocebo response.

A difference between antipsychotic and antidepressant discontinuation is the clear evidence for the development of dopamine receptor supersensitivity. Physical effects may therefore be important but it is not clear to me that dopamine supersensitivity is responsible for antipsychotic discontinuation problems. Certainly tardive dyskinesia can be made worse by antipsychotic discontinuation, which is a physical effect, but dopamine supersensitivity may merely be significant for motor rather than psychological symptoms.

I have also always been cautious about the argument that 'antipsychotics should not be used because they cause brain damage' (see previous post). Actually this effect has always been clear, at least for traditional neuroleptics, because of the potential irreversibility of tardive dyskinesia.

Anyway, I'm glad Robin is now recognising the much neglected research question about whether people who manage to deal with their problems without medication may actually do better in the long-term.

5 comments:

Diana Rose
said...

Well it all depends on what you mean by psychological. Having taken 9 months to very slowly come off olanzapine, my main 'discontinuation ' effects were terrible insomnia and sometimes racing thoughts. Squares absolutely with supersensitivity and up regulation and v hard to distinguish withdrawal from 'relapse'. Felt pretty much psychological to me. Anecdote I know.

Depends what you mean by psychological. 9 months v slowly coming off olanzapine main effects awful insomnia and racing thoughts. Squares completely with supersensitivity and up regulation and v hard to distinguish withdrawal from 'relapse'. Felt pretty much psychological to me. Anecdote?

Say it as often as you like - it needs to be shouted as loudly as possible. So many people still keep quiet while they come off drugs in fear of the consequences if they ask for help to do that. How long does it take before the people who are affected by over prescribing get listened to and given the choice of treatments, should they want them, they are entitled by law to be advised of - it has taken decades for the issue to be openly talked about by medics. Shame on them.

I think psychiatrists need a taste of their own medicine, over a period of months or even years. Many of them may indeed be on their own drugs and find it difficult, if not impossible, to get off them.

I tapered and got off Chlorpromazine, twice after a year, following puerperal psychoses in 1978 and 1984. Then did the same with a cocktail of psych drugs: Risperidone, Venlafaxine (max dose) and Lithium, after menopausal psychosis 2002. Had to do it myself, then inform psychiatrist who tried to discourage me by saying I had a "lifelong mental illness". No I didn't. Despite his quoting of the DSM chart of diagnoses. Didn't believe in it.

In my experience antipsychotics were like mind control drugs, taking away my agency, leaving me depressed and dull, flat mood, agitation, anxiety and low quality of life. I couldn't have survived on these drugs. I took an overdose of venlafaxine pills 2002, on impulse, a side effect I found out years later. I'd felt guilty for years at doing such a thing. Now I blame psychiatry.

We need alternative ways of working with people experiencing psychoses, altered minds states and extreme emotional distress that doesn't just mean forcing drugs into us. That's too easy for psychiatry. Too hard for psychiatric survivors.

It's one thing to talk about antipsychotic side effects, disabling long term effects and discontinuation effects. Quite another thing to experience it for yourself, Dr Double. Which is why the voices and stories from psychiatric survivors, people who are still around to tell the tale of what it's really like, are of paramount importance and value. Superceding the theories and biased research from "experts" who haven't been at the sharp edge of an antipsychotic syringe, pants down, forced to conform.